12/15/2022    Paul Kesselman, DPM

Save Bunion Surgery as a Last Resort: DC Podiatrist (Philip Wrotslavsky, DPM)

While in practice, I rarely performed bilateral
foot surgery. This was long before the 50%
reduction in payment and I for one can’t blame my
colleagues for not wanting to perform more
procedures at 50%, when 100% is already far from
fair compensation. However, my philosophy of
performing surgery on one foot at a time was done
because I wanted patients to have the ability to
place weight on the opposite extremity and avoiding
balancing and other cardiovascular loads that I
knew patients, especially elderly patients could
not handle if performed bilaterally.

Unilateral surgery would be a challenge enough for
most. Why on earth would one wish to place a
patient into a greater risk category? Patients
often do not know what is best for them and maybe
short-sighted attempting to use reduce sick time
and additionally negating the need to undergo
anesthesia twice is likely insufficient a reason.

Bilateral surgery could certainly reduce anesthesia
time, but only if the bilateral surgery is
performed as a team, with two working on the
patient simultaneously. Bear in mind that the
literature also suggest that patients who are
sedentary and NWB post operative and who are
elderly are also at a greater risk for DVT, PE and
other complications that come with. Being sedentary
for the protracted period of time also will serve
to further deconditions the patient.

Having many colleagues in the orthopedic field, I
questioned about performing bilateral knee or hip
surgery. Most were emphatic that they would rarely
perform bilateral hip/knee surgery (less than 5% of
the time) and then only on selected patients mostly
because of pain issues and the other issues I’ve
already mentioned. They further commented that
bilateral knee TKA also had higher infection rates.
In forty years of practice, I only saw one patient
who had undergone bilateral TKA done at one time.
He did well. But he is the exception! The few I saw
who had undergone these procedures bilaterally told
me that had they had to make the decision again,
they would never do it again.

Multi-trauma patients are of course another story,
but they did not have the option to ask about
scheduling.

Paul Kesselman, DPM, Oceanside, NY

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12/12/2022    Richard Jaffe, DPM

Save Bunion Surgery as a Last Resort: DC Podiatrist (Philip Wrotslavsky, DPM)

When I retired at the end of 48 years, my practice
was exclusively private foot surgery for cash. I
found that with performing mostly open incision
Scarf bunionectomies, Weil osteotomies, and
arthroplasties with modern fixation, almost all of
the patients experienced very little or no pain
postoperatively. Other than an NSAID, there was no
pain medication necessary. Therefore, almost all
cases were performed bilaterally and ambulatory.

Of course, post-op they mostly sat with their legs
elevated with minimal walking, but there were no
crutches, casts, or boots and they could take care
of themselves. The patients were grateful that they
could have all the work done on both feet in one
operation. Most surgeons would not do it.

I performed thousands of cases this way. I’m sure
that this is not something new to the profession.
But, due to these techniques, I believe that NOT
doing cases bilaterally is a disservice to the
patient. Recovery is long in all cases where the
bone is incised and a study showed that two feet
heal as fast as one foot. These are important
issues to the patients and this is a great way to
go if you want to develop a strong following of
people who need surgery.

In addition, I don’t remember ever seeing a painful
bunion that got better by itself without surgery.
Almost all of these deformitie are progressive and
will only become more severe. Consequently, once
there is pain from the deformity, then repair is
justified whenever the patient wants it. It will
only get worse through neglect (Ex. Dislocated
MPJs). Why postpone it until the patient is old and
more compromised? All such experiences are more
difficult for the older patient.

I would like to take this opportunity to thank Dr.
Lowell Weil for generously being a guiding light in
my professional life since I met him in 1970. He
and Dr. Steve Smith had a profound positive
influence on the profession of my generation.

Richard Jaffe DPM, Jerusalem, Israel